Modified presurgical nasoalveolar molding in the infants with complete unilateral cleft lip and palate: a stepwise approach

Abstract

Presurgical orthopedics in one or the other form has been an important part of the multidisciplinary approach towards the better cleft care. Presurgical nasoalveolar molding (PNAM) was described as a modified approach to the conventional form of orthopedics. PNAM not only reduces the severity of the alveolar defect before surgery, it also reduces the nasal deformity bringing it near to the normal. Nonsurgical nasal correction forms an important adjunct to the primary nasal repair at the time of primary lip repair. However, acceptance of nasoalveolar molding in Indian set-up has not been wide spread due to various reasons such as lack of the resources and inability of the parents to comply with the frequent adjustment schedule. At the Nitte Meenakshi Institute of Craniofacial surgery at the Nitte University, Mangalore, authors have developed a modification of the PNAM appliance previously described in the literature. The key modification is done at the time of fabrication of the occlusal prosthesis. This modification has made the overall procedure simpler and at the same time helped to reduce the recall visits by half of the originally required. This article describes the fabrication procedure of the modified nasal alveolar molding appliance and the modified treatment protocol in a stepwise manner.

Keywords: Deformation; Malformation; Nasoalveolar molding; Presurgical orthopedics.

Fig. 1

Intra oral impression poured with dental stone to obtain accurate cast used for making appliance

Fig. 2

Cleft space and undercuts obliterated with the modeling wax and spacer is added on to the palatal side of major segment

Fig. 3

Occlusal plate is fabricated over the dental model, polished and properly relieved in the labial frenum region

Fig. 4

Occlusal appliance in place with lip taping

Fig. 5

PNAM appliance with a nasal stent attached to the retention arm

Fig. 6

PNAM appliance in place with nasal stent adequately supporting the cleft nasal cartilage

Fig. 7

An infant with right unilateral cleft lip and palate treated with the modified appliance and the modified treatment protocol. a Patient at 5 days of age showing stretched cleft nasal cartilage over widely separated cleft lip segments. b Same patient after completion of nasoalveolar molding showing approximation of cleft lip segments and improved symmetry of the nose. c Typical cleft nasal deformity with lateral splaying of the lower lateral nasal cartilage and caudal displacement of the medial crus of the cartilage. d Improved nasal cartilage morphology and elongation of columella on the cleft side. e Alveolar cleft gap in the beginning of the treatment. f Alveolar cleft segments have approximated by alveolar molding. g Same patient after the primary lip-nasal repair showing symmetrical nostrils